MEDICARE: HIMA GORANTLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PH00054737	WA

General Provider Information

NPI Number	:	1194127266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HIMA GORANTLA

Provider Business Mailing Address
First Line	:	3721 222ND PL SE
Second Line	:
City	:	BOTHELL
State	:	WA
Zip	:	98021-4221
Country	:	US
Telephone Number	:	360-386-4615
Fax Number	:	360-386-4609

Provider Business Practice Location Address
First Line	:	4010 172ND ST NE
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-8482
Country	:	US
Telephone Number	:	360-386-4615
Fax Number	:	360-386-4609

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2014
Last Update Date	:	09/20/2014

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Directions to “ HIMA GORANTLA ” Practice Location

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